Free CRST Incident Investigation Methods Questions and Answers — Questions and Answers
Question 1: A minor incident occurs where a worker slips on a small oil patch but is not injured. A supervisor cleans the spill and tells the worker to be more careful. From a modern safety management perspective, what is the primary failure in this response?
- The supervisor failed to discipline the worker for inattention.
- The incident was not reported to the provincial workers' compensation board.
- The opportunity to identify and correct the root cause of the spill was missed. (Correct answer)
- The supervisor performed the cleanup instead of a designated cleaning crew.
Correct answer: The opportunity to identify and correct the root cause of the spill was missed.
Modern incident investigation focuses on prevention, not blame. Ignoring a near miss, like a slip without injury, means failing to investigate *why* the hazard (the oil patch) existed in the first place. This misses the opportunity to correct the underlying system failure (e.g., leaking machine, poor maintenance procedure) and prevent a future, potentially serious injury.
Question 2: Which of the following is the primary objective of a root cause analysis (RCA) during an incident investigation?
- To identify and correct underlying safety management system deficiencies. (Correct answer)
- To determine the sequence of events and the direct cause of the incident.
- To satisfy the minimum legal reporting requirements for the jurisdiction.
- To assign accountability to the individuals involved in the incident.
Correct answer: To identify and correct underlying safety management system deficiencies.
The primary goal of root cause analysis is to move beyond the immediate and contributing causes to find the fundamental deficiencies in the safety management system. By correcting these systemic issues (e.g., inadequate training, poor design, lack of procedures), an organization can effectively prevent similar incidents from recurring.
Question 3: An investigator is using the "5 Whys" technique to understand an equipment failure. What is the fundamental process of this method?
- Asking five different witnesses for their perspective on the failure.
- Brainstorming five potential causes in a group setting.
- Identifying five key contributing factors from a standardized checklist.
- Sequentially asking "Why?" to trace the cause-and-effect chain to a systemic failure. (Correct answer)
Correct answer: Sequentially asking "Why?" to trace the cause-and-effect chain to a systemic failure.
The "5 Whys" is an iterative technique used to explore the cause-and-effect relationships underlying a problem. By repeatedly asking "Why?" (five times is a general rule), the investigation can move past the obvious symptoms and uncover the deeper, systemic root cause of the failure.
Question 4: Immediately following a serious incident involving a machine, what is the most critical first step for the responding supervisor after ensuring medical aid is provided and the scene is safe from immediate danger?
- Interviewing all witnesses while their memories are fresh.
- Securing the scene to preserve evidence. (Correct answer)
- Repairing the machine to minimize production downtime.
- Notifying the provincial ministry of labour of the incident.
Correct answer: Securing the scene to preserve evidence.
After ensuring the injured are cared for and the scene is safe from further harm, the highest priority is to secure the area. This involves preventing unauthorized access and ensuring that physical evidence (e.g., equipment position, debris, controls settings) is not disturbed, moved, or cleaned up. Preserving the scene is essential for an accurate investigation.
Question 5: James Reason's "Swiss Cheese Model" is a widely used framework for analyzing incident causation. What do the "holes" in the slices of cheese represent in this model?
- Failures and weaknesses in the system's layers of defence. (Correct answer)
- Unsafe acts committed by frontline workers.
- The number of injuries resulting from an incident.
- Random, unpredictable events that cannot be prevented.
Correct answer: Failures and weaknesses in the system's layers of defence.
In the Swiss Cheese Model, each "slice" represents a layer of defence or a barrier in a system (e.g., procedures, training, equipment guards). The "holes" represent weaknesses or latent failures within these defences. An incident occurs when the holes in multiple slices align, allowing a hazard to pass through all layers and cause a loss.
Question 6: During an incident investigation, it was found that an employee removed a required machine guard to clear a jam. How would this action typically be classified in a cause analysis?
- A root cause
- A latent failure
- An indirect cause (or contributing factor) (Correct answer)
- A direct cause
Correct answer: An indirect cause (or contributing factor)
The removal of the guard is an unsafe act. Unsafe acts and unsafe conditions are considered indirect causes or contributing factors. They are symptoms of a deeper problem but not the problem itself. The root cause would be *why* the worker removed the guard (e.g., inadequate procedure for clearing jams, lack of training), and the direct cause would be the subsequent contact with moving parts.
Free CRST Incident Investigation Methods Questions and Answers
A minor incident occurs where a worker slips on a small oil patch but is not injured.
A supervisor cleans the spill and tells the worker to be more careful.
From a modern safety management perspective, what is the primary failure in this response?